Eleanor Nursing and Social Care Ltd - Oxford Office

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The service had a values statement which indicated their commitment revolves around five core values of Trust, Respect, Empowerment, Innovation and Fulfilment.

Staff were positive about the culture of the agency, which was described as open, positive. supportive and inclusive. Staff commented, “There is an open culture at Eleanor Nursing and Social Care. Workers have the right to voice their concerns”, and “The culture of the agency is supportive, professional, and focused on teamwork. Staff are encouraged to communicate openly, share ideas, and provide feedback. For example, regular team meetings help address concerns, while management ensures staff have the training and resources needed to perform their roles effectively. The agency also promotes respect and empathy in caring for service users, fostering a positive and collaborative environment.”

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. They acknowledged that the high turnover of reablement packages impacted their ability to consistently keep records updated and this was reflected in our findings around people’s records.

Staff were happy with the way the service was managed. They described the registered manager as ‘fair, kind, approachable and listens’. Staff commented, "It's managed well. They care about the people we look after, and they look after us too. It makes it a good place to work,” and “[Registered manager’s name] is democratic, collaborative, team oriented, empowering and results driven. They are inspiring, humble, trustworthy and communicative.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The provider had systems in place to promote speaking up. These included a whistle blowing policy, team meetings and supervisions. Staff described the management of the agency as supportive and approachable with the registered manager having an open-door policy for raising concerns. Staff commented, “[Registered manager’s name] management style is supportive and approachable. They encourage open communication, listens to staff concerns, and provides guidance when needed”, and “There is an open culture, workers have the right to voice their concerns and are listened too.”

People and staff were surveyed. The results of the people surveys completed in September 2024 were mainly positive, although no comments or actions were provided to us to be assured of the content of the feedback. The staff survey was completed in February 2025. These were for all staff of the provider as opposed to being specific to the Oxford branch.

Monthly staff meetings took place to keep staff updated on changes within the service. A newsletter was also provided to further update staff on forthcoming changes.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider had an equality and diversity policy, and staff were trained in equality and diversity. The service had a diverse group of staff employed. Staff told us they were treated equally, fairly and their diverse needs were considered. Staff commented, “I feel equally and fairly treated with respect. The agency takes note of the diverse needs of workers and service users and promotes equality, ensuring all staff and service users are treated with respect”, and “Yes, I feel treated equally and fairly at work. The provider promotes equality by ensuring all staff are respected, regardless of background or role, and encourages a diverse and inclusive work environment. The agency also ensures that service users' diverse needs are met by tailoring care plans to their specific cultural, religious, and personal preferences, ensuring that everyone receives personalized and respectful care.”

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Provider and registered manager audits of care plans and medicine records were taking place. However, these were ineffective as they had not picked up the issues we found with care plans, lack of risks assessments and medicine management. For example, the quality manager audit completed and dated as January 2025 reviewed 2 of the care plans, we had reviewed. Whilst they identified the medical care plan needed to outline how medical conditions impacted the person it did not identify the issues, we found with those care plans in relation to risk management and lack of mental capacity assessments. There was no action plan for this audit to ensure the issues they had identified were addressed.

The providers’ regional audit for March 2025 included the audit of a care plan we had reviewed. We found risks relating to falls, tissue viability, the person’s door left insecure, and the lack of mental capacity assessments and best interest decisions were not identified by the audit and mitigated. Therefore, auditing was not effective in identifying shortfalls in the service.

The human resources department, registered manager and regional manager audited a sample of staff files. Rotas and care calls were audited by the provider ‘s electronic system. However, audits of training were not taking place to ensure staff had the skills for the tasks they were undertaking. This was not in line with the providers’ policies such as the risk management and supervision policy.

In response to the draft report the provider sent us a copy of the provider’s internal audit carried out in March 2025. This had identified some of the issues we found, however these were not always promptly actioned.

The service was not working to the providers policies in relation to risk management, medicine administration, mental capacity assessments, induction and on boarding. This was not identified through auditing to ensure consistency and compliance.

People’s records and records relating to the service were not always suitably maintained and accurate. Some people’s records were contradictory as to whether they were self-medicating, mobilising with or without aids and whether they had capacity or not. For 1 person the medicine outlined in their care plans was not reflective of the medicine recorded on their MAR.

Some people’s daily records were illegible, and terminology used was not in line with best practice. For example, daily records referred to ‘incontinence, feeding and wandering.’ These descriptors did not promote a respectful approach to care. The provider had already identified this was an area for improvement and they had produced a ‘Power of Language’ document to remind staff of the importance of using the right language to empower people and promote a respectful approach.

In response to our feedback the provider took immediate actions to improve their auditing processes to ensure their audits were effective in identifying shortfalls in their governance.

The provider did not always understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement.

We received positive feedback from 1 professional in relation to their recent engagement with staff at the service. We were aware the service had an improvement plan in place with the Local Authority. Progress in making and sustaining those improvements were continuing.

The service worked closely with health professionals in the discharge of people from hospital to home. We noted in people’s records that staff did not routinely inform family and or health professionals when changes were recorded in people’s health and well-being. There were also inconsistencies in them reporting to the services office which did not promote working in partnership to benefit people.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The service had put systems in place to promote learning following an incident where a person died as a result of complications of their medical condition. However, the medical care plans put in place did not include the signs and symptoms of a deterioration in a person’s medical condition to alert staff to take action and prevent risks to the person. The provider assured us their staff had access to information sheets in people’s homes which outlined the signs and symptoms of medical conditions to mitigate the risks to people. The provider took immediate actions to update care plans to include signs and symptoms of risks associated with medical conditions.

Accident and incidents were reported to the office. The lessons learnt section of the accident log indicated what needed to happen, for example risk assessments to be updated. However, the actions were not checked to ensure they were completed to demonstrate learning and promote improvement. As a result, we saw that following a fall, a falls risk assessment was not put in place, despite the accident log indicating that was required to promote learning.

Staff told us there were several systems in place to promote learning and encourage innovation. These included regular training sessions, workshops, and access to online resources. They commented, “Staff are encouraged to share new ideas during team meetings, and feedback is actively sought to improve care practices. Additionally, there are opportunities for staff to attend conferences or courses that enhance their skills, fostering a culture of continuous improvement and innovation in care delivery”.